Conducting MVI Investigations: Step 1: Respond To The Incident

Conducting MVI
Investigations
Step 1: Respond to the Incident
If he or she is able to do so, your employee(s) at the
crash scene should immediately:
1. Check themselves for injuries
2. Secure the scene and take steps to ensure
further harm does not occur (e.g., control traffic)
3. Provide all reasonable care for people who may
have been injured
4. Contact, or have someone else contact 911 to
alert emergency responders
5. Notify his/her supervisor or employer
6. Begin collecting information (see below)
As soon as they are aware of the

crash, the designated manager should
prepared and know what information to
confirm emergency resources have
collect, and how to collect it.
been mobilized. They must then
To ensure your employees know what
decide (and/or check the company’s
to do if they are involved in a crash,
policy) if they will send a company
download If You’re Involved in a Crash
representative to the crash scene. If
Checklist. Keep a copy in all work vehicles.
a company representative attends the scene, upon
arriving they should:
Download the MVI Investigation Equipment
1. Verify the scene is safe and secure to avoid
Checklist for a list of the supplies and tools for
disturbance of information
collecting and processing crash scene information.
2. Assist in providing all reasonable care, if
Once witnesses leave the scene you might not be
necessary
able to find them, or they may soon forget what they
3. Begin or assist with collecting information
saw or heard. Start collecting vital information as
4. Cooperate with enforcement officers and
soon as possible - especially information that may
emergency responders
disappear quickly.
5. Initiate reporting the incident to authorities (e.g.,
police, insurance company, WSIB, MOL or ESDC)
There are several methods used to gather
information about an incident:
A quick and effective response is the best way to
prevent further injury or harm and avoid additional 1. Examine the site
losses. It’s part of your due diligence. 2. Take photographs
3. Make sketches
Step 2: Gather Information 4. Interview people
The main purpose of gathering 5. Let modern technology help
information is to establish facts that
describe the sequence of events that Examine the site
occurred before, during and after the The first thing to do is to survey the scene to identify
crash. Clear and complete information hazards that have not yet been neutralized - and
enables investigators to re-create events with address or avoid them! Then, identify the pieces of
accuracy, and understand what happened. Crash information you need to gather.
scenes can be chaotic so it is important to be
Look closely for clues. What looks unusual or Take photographs
out of place? Debris may be scattered over a
large area. What do tire tracks tell you? Photographs are the best way to document
Look inside the vehicle(s). Is it a well- information. Below is a list of photos to
organized workplace or cluttered with gather at a crash scene.
items that obstructed the driver? Is there 1. positions of all vehicles involved
a smartphone with a half-finished text? An open 2. inside and outside damage to vehicles involved
make-up kit? If you think it can help piece the 3. locations of crash-related debris
events together, take a photo or make notes. 4. injuries to any person (get consent of that
person before taking photos)
Looking for Clues 5. position of injured persons (if thrown from the
Each crash can have an array of possible vehicle)
underlying causes. As you examine the scene for 6. eyewitness viewpoints - helps describe what
information, use the framework below to help ask each witness could, and could not, see
the right questions. 7. environmental conditions and physical factors
(e.g., a setting sun that impaired visibility, an
1. Physical factors – Did mechanical (e.g., icy patch of road, an improperly secured load, a
unfit vehicle, unsecured load, worn tires), defective brake part, etc.)
environmental (e.g., weather, road), material
(defective traffic control device) or other Suggestions for taking crash scene photos
factors contribute to the crash? These days, nearly everybody has a camera on his or
2. Human factors – Did a person (e.g., driver, her phone. Check with observers to see if they have
passenger, pedestrian, supervisor) do, do crash photos they are willing to share.
incorrectly or incompletely or fail to do
something that contributed? Were physical or Make sketches
mental conditions (e.g., fatigue, state of mind, Sketches of the crash scene are valuable tools
skill level) factors? because they convey information
3. Organizational factors – Do you see or hear that photos usually can’t. Start with
things that cause you to wonder if policies or not-to-scale sketches drawn at the
procedures were in place, or that insufficient site. Use the measuring tape in your
training, inadequate supervision or improper kit to measure distances, or estimate
motivations are factors? using your paces. Later, use your
measurements to build a scale diagram.
Developing your own initial theory of what
happened can guide you to collect Interview people
necessary information. However, don’t Interviews are essential. Sometimes, they are the
let your theory (or anyone else’s) blind only way to find out what happened and why. Speak
you to information that will lead you to with the people involved in the crash and with those
a correct analysis. Look for facts. who observed it.
In collaboration with WorkSafeBC. The information contained in this document is for educational purposes only. It is not intended to provide legal or other advice to you, and you should not rely upon the information to provide any such
advice. We believe the information provided is accurate and complete; however, we do not provide any warranty, express or implied, of its accuracy or completeness. Neither IHSA, WorkSafeBC, nor Road Safety at Work shall be liable in
any manner or to any extent for any direct, indirect, special, incidental or consequential damages, losses or expenses arising out of the use of this form. September 2018.
Others may have information about events or asking questions like, “What happened next?” or
circumstances before and after the crash - the “Was that before or after ____?”
supervisor who provided direction, • Consider asking, “Why do you think that
someone the driver spoke with happened?”, or “What could have been done to
at the last delivery, a motorist or avoid this crash?” Such questions can bring out
pedestrian who saw this vehicle key information, but the associated speculation
approach the intersection. may or may not be correct.
Investigations may lead you to • Avoid interruptions. If you have questions, wait
seek information outside the workplace. Maybe until the interviewee finishes, then ask.
something that happened this morning at home, at • During the interview, periodically summarize and
last night’s hockey game or some other non-work repeat it back to the interviewee to make sure
event has influenced a driver’s decisions and actions. you have it right.
• Offer to share your notes or audio recordings
Usually, people involved in a crash didn’t see or can’t with each interviewee to check that you have
recall everything that happened. Crash witnesses correctly captured their words.
aren’t often able to mentally record and recite all • Give the interviewee your contact information.
of the details. Investigators often have to piece Ask them to call if they think of anything else.
events together using information they discover by • Thank them for their help.
interviewing several people.
As you speak with people, seek to determine:

1. When the incident occurred
2. Where they were when it occurred; this will help
you understand what they could, and could not
see from their vantage point
3. What they saw and heard; their account of what
happened and the sequence of events.
Interviewing people is somewhat of an art. Here

are a few ideas for eliciting helpful
accounts.
• Interview observers as soon as
possible. At the crash scene is
usually best as long as they are not
injured or visibly upset. You can also follow-up You might encounter interviewees who provide
and clarify during a later interview. inconsistent, incomplete, incorrect or purposefully
• Conduct interviews individually and privately, misleading information. Sort through their
without interference from others. motivations to decide if their statements are of value
• Put interviewees at ease. Rather than to the investigation.
demanding they “provide their statement for the
investigation”, ask them to simply describe what
Let modern technology help
happened.
Nearly all new cars sold in Canada today are
• Ask open-ended questions. Avoid questions that
equipped with Event Data Recorders (EDR).
lead the interviewee to guess, or to agree with a
Originally designed to help ensure air bags deploy
suggested occurrence.
in the event of a crash, today’s EDRs track a range
• Take the interviewee back through the events by
of specific data including vehicle speed, steering
and braking actions, acceleration and seatbelt use to
name a few.
Different EDRs have different features. Some record 2. It provides a framework for asking important
data in a continuous loop of a set questions.
duration. Others are activated by
a crash or crash-like event. Either For each known event, ask whether another event
way, the information they collect should have happened before or after it. For
can establish key facts and valid evidence. Vehicle example, a left turn should be preceded by the
owners can work with their local dealership to driver activating the left turn signal. If something
retrieve data. should have happened but did not, make a note and
find out why.
Dash-cams are increasingly common. Check vehicles
involved in the crash. Perhaps another motorist at or
near the crash scene captured footage of the events.
Plus, with the increasing number and variety of
traffic cams, surveillance cameras and other closed-
circuit TV systems, there may be other sources to
help you verify crucial facts. Ask around.
You may want to gather other documents that are

relevant to the investigation - vehicle inspection and
maintenance records, driver’s licences and driving
records, risk assessments, trip plans, recent work
schedules, driver training records, tailgate and safety
meeting notes, etc. Step 4: Determine Underlying Causes
Each of the facts - actions, decisions and conditions
Step 3: Map the Sequence of Events - established in the previous steps is an opportunity
Using the information you gathered - to ask, “why?” Testing and analyzing the theories the
photos, measurements, statements, your team develops is an iterative process during which
own well-reasoned theory and relevant data you discover important new facts and possible
- re-create the incident as a chronologically explanations.
ordered series of events/ diagram that
demonstrate what happened before, during Referring to the sequence of events diagram, ask
and immediately after the crash. “why” repeatedly until you identify the unsafe
conditions, acts or procedures that contributed
Sometimes critical decisions are made and key to the incident. Write down the answers. As you
events happen well before the crash. If it had a ask and answer these questions, you will see other
bearing on the crash, it belongs in the sequence of questions. Remember to explore details, even when
events. they aren’t obviously key facts.
There are two reasons for re-creating the events in a Answers to the initial series of “whys” provide
visual way. clues about immediate causes. Continuing to
1. It is an efficient visual summary of what probe and ask “why” again will lead investigators
happened; others can review the diagram to to discover the root or underlying causes - the
verify the description is accurate and the “flow” more fundamental circumstances that caused or
agrees with what they saw. contributed to the crash.
Immediate causes - unsafe or substandard acts,
practices or conditions that lead directly
to the incident. These include things like
driving a vehicle with worn out tires or
while knowingly impaired by stress or
fatigue, lack of concentration, speeding,
not knowing or failing to follow a safe work
procedure, etc. Immediate causes are symptoms of
the underlying causes of the incident.
Root or Underlying causes - explain why

the immediate causes occurred; they are the
organizational circumstances that allow unsafe
conditions to exist, the conditions that facilitate
unsafe decisions and the fundamental reasons
behind unsafe actions. They include inadequate work
planning, unrealistic work demands, incomplete Will inspections catch mechanical failures before
systems, incorrect procedures and many others. they occur? Is the maintenance program all that it
should be? Is there a gap in the personal vehicle
Step 5: Recommend Corrective Actions fleet policy that allowed an employee to use their
The core reason for examining crashes is to identify seriously deficient vehicle for work? How does the
corrective actions the organization will take to organization manage the trips employees take? Why
ensure other crashes do not occur because of the was that employee delivering parcels when road
same acts, conditions or decisions that caused this conditions were treacherous? How do we strengthen
crash. Corrective actions should speak directly to our policies and how they are applied?
the underlying causes identified in your analysis.
Human factors
Sometimes when you examine the facts it will be Think about the people involved, their actions and
apparent that your employee did inactions. Determine what they can
everything right - the actions or do differently to prevent recurrence,
omissions of a third party caused the and how they can be equipped
crash. It’s still worth looking for ways to and motivated to do so. Focus on
prevent reoccurrence (e.g. training on practices and behaviours that the
crash avoidance techniques) but there is little value company can control or influence. For example, if
in looking for corrective actions that simply aren’t driver fatigue was a key factor the recommendations
there. could spotlight:
Use the framework below to determine what 1. What the employer and owners can do to make
corrective actions to recommend. sure fatigue management is a safety priority
2. What managers can do to ensure employees
Organizational factors understand fatigue and what they can do to
For work-related crashes, much of the responsibility avoid it
for changes aimed at preventing future crashes falls 3. How supervisors and employees can collaborate
to the organization. The company sets the policies to build schedules that avoid long driving
and procedures by which it requires employees assignments
to drive. The company is responsible to equip 4. How individual employees can self-manage and
their employees with the training and supervision self-assess to know when they are fatigued, and
necessary to operate work vehicles, and to ensure be empowered to pull over and rest.
work vehicles are fit for purpose. It is imperative that
investigators look closely at organizational factors as
they develop corrective actions.
Physical factors Summary
If mechanical failures or conditions figured in the A brief summary of the incident including:
crash, consider the vehicles used for 1. Who was involved; description of vehicle(s)
work. Are they designed and equipped involved
so that they are fit for the purposes they 2. Depending on how the investigation report will
are used? Do they have the right safety be distributed, it is often appropriate to exclude
equipment? If environmental factors names and other personal information of the
contributed to the crash, the organization people involved and witnesses. Instead, identify
can do very little to control the weather, individuals as Driver A, Pedestrian B, Observer C,
but they can do quite a lot to manage if, when and etc.
how their employees drive during adverse weather 3. What happened - use the sequence of events;
conditions. Build recommendations around that include suitable photos of the scene
understanding. 4. When it happened - date, time; state day of the
week or “day 11 of 12-day shift”
It’s often tempting for investigators to make a 5. Where it happened - location, address and
“shopping list” of corrective actions - a long list of qualifiers (e.g., busy street, steep hill) if relevant
actions would be nice to do, but is rarely completed. 6. Names and roles of people investigating the
Challenge your investigation team to arrive at the crash
ONE THING that must be done to make sure this
crash does not happen again. Keep the corrective Conclusions
actions list short, clear - and doable. Provide an overview of WHY the
incident occurred, as determined
Building the Report by the investigation. Summarize the
There are several formats for building a report. immediate and underlying causes.
Choose one that works well for people in your
organization. Often, a well-structured investigation Recommendations
form can serve as the foundation for a well- List the main recommendations aimed at preventing
organized report. Below is a framework you can use similar future events. Use a table that links each
to build incident investigation reports. recommendation to the condition or finding that
prompted it:
Recommended
Underlying Cause
Corrective Action
Improper planning RWC should develop

and unrealistic and implement
scheduling: a procedure to
build and verify
Crew was assigned achievable work
three extra pick- schedules.
ups with no
accommodations for
mandatory pick-ups.
These first three sections - the summary, conclusions

and recommendations - are what most of the people
who receive the report will actually read.
Main Report Step 6: Implement Corrective Actions
Now it’s time to take action. The investigation team
1. Purpose and Objectives explained how the organization can make changes
Explain why the organization conducted the to prevent similar incidents. Put that knowledge to
investigation and what it expected to work as soon as possible.
achieve. Beyond the core objectives
of identifying root causes and finding Once they review the report with the management
ways to prevent recurrence, there may team, investigation team responsibilities are
also be legal requirements, company policies and complete. Upper management must decide
other reasons to consider. what actions the organization will
implement, assign responsibilities,
2. Incident Description allocate resources and set completion
Use factual statements to describe the events that
dates. It can take considerable time
happened before, during and immediately after the
to activate solutions to address deep-
crash. Provide details about who, what, when and
rooted underlying causes. However,
where. Include relevant peripheral events or factors.
investigations usually reveal matters that demand
3. Investigation Methods immediate attention by supervisors and managers.
Describe the investigation team - participant names, As that occurs, the organization should also:
positions and qualifications. Explain • track corrective actions to ensure they are
site visits made. Insert photographs, carried out by the designated date
sketches and diagrams that contribute • evaluate how effective the recommended
to the explanation. Describe interviews measures are
conducted and summarize what was • periodically audit the system to verify measures
learned. If you conducted any simulations, tests or remain in place, and effective.
reconstructions, include the results here.
4. Findings
Organize the findings - what was discovered,
confirmed or learned - so readers can easily
follow the facts and logic used to develop the
recommendations.
5. Recommendations
In addition to dealing with underlying causes in a
comprehensive manner, explain the
contributing factors and causes, and
how they figured in the events and
the incident. Link recommendations to
findings.
6. Appendix
This information is important to the investigation
but not essential to understanding the report and its
recommendations. Include raw data and statistics,
supporting diagrams, photos and interviews, a root
cause analysis chart, copies of relevant documents,
etc
Corrective Action and Completion Table
Expected
Corrective Action Assigned to Completion Completion
date
date
Immediate Action - Review Raj - RWC

the incident with RWC teams; safety
focus on the underlying causes and coordinator; March 30, 2019 March 19, 2019
circumstances that contributed to the include Michelle
incident, and what changes RWC will and/or Carl
make to prevent similar events
Immediate Action - Request that

Tina - RWC March 10, 2019 April 4, 2019
bin owner relocate the bin to the rear
of the restaurant so RWC can easily operations
access it from Fulton Avenue. manager
Near Term - Reinforce company

appreciation / expectation that Lorne - senior
April 15, 2019 April 15, 2019
employees make safe decisions and
VP; at next
follow procedures rather than take
quarterly safety
unnecessary risks.
mtg
Near Term - Develop and implement

a process in which a) supervisors and
Tina - RWC
dispatchers work with crews to build May 14, 2019
operations May 15, 2019
realistic routes and schedules, and b)
manager
supervisors review route and schedule
changes with the driver before
assigning that work.
Here is an example of a simple table that will help the organization track its progress.

Conducting MVI Investigations: Step 1: Respond To The Incident

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Conducting MVI

As soon as they are aware of the

As you speak with people, seek to determine:

Interviewing people is somewhat of an art. Here

You may want to gather other documents that are

Root or Underlying causes - explain why

Improper planning RWC should develop

These first three sections - the summary, conclusions

Immediate Action - Review Raj - RWC

Immediate Action - Request that

Near Term - Reinforce company

Near Term - Develop and implement

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